Aesthetics and Wellness

Aesthetic medicine is often perceived as being a counterpart to healthcare. Many aesthetic treatments, of course, are considered elective and are not covered by health insurance. As the science behind the best ways to make patients look better continues to evolve, however, considerable overlap has been identified between aesthetics and wellness. Modern Aesthetics spoke with three physicians who have been on the cutting edge of this intersection through their work with regenerative medicine and other aesthetic treatments that involve overall wellness.

Elizabeth Yurth, MD, is double board-certified in physical medicine/rehabilitation and anti-aging/regenerative medicine, with more than 30 years of clinical experience. She is the co-founder and chief medical officer of the Boulder Longevity Institute in Boulder, Colorado.

Cambria A. Judd, MD, is a sports medicine specialist and a pioneer in the stem-cell treatments. She is the founder of Beyond Functional Medicine in Newport Beach, California.

Sandra Kaufmann, MD, is a fellowship-trained pediatric anesthesiologist who turned her knowledge of cell biology, human pharmacology, and physiology into a new career. She is the founder and CEO of the Kaufmann Anti-Aging Institute in Miami, Florida.

PEPTIDES FOR BOTH WELLNESS AND AESTHETICS

How much overlap exists between aesthetics and wellness as it pertains to longevity?

Dr. Yurth: This is a huge and very underappreciated topic. Despite some modest evolution, for the most part, aesthetic clinics are still doing primarily aesthetics. However, health span is such a big part of aging. We can work all the magic in the world and our skin will still age. It will still get saggy. So much can be done internally, however—by replacing hormones, by replacing peptides, and by ensuring good mitochondrial health. That should be the focus of how we can maintain the results of our aesthetic procedures. People can continue to look good and feel good for a long, long time. Right now, aesthetics and wellness tend to be placed into two separate buckets, but they should not be.

How much of that is physicians and how much of it is patient demand?

Dr. Yurth: We are seeing progress on both sides, but it is slow. At the Octane Aesthetics Tech Forum in January, we had a panel discussion with physicians who are implementing more longevity tools in their practices, optimizing hormones, and ensuring that their patients are utilizing peptides and other resources to help the body function at a much higher level. The knowledge base is still very basic, however, and I don’t know that it is reaching people very well. There are still a lot of people who just want their neurotoxins, their lasers, or their skin creams; they are not really addressing the key longevity factors, such as lack of estrogen causing skin to lose its elasticity. In the general population of people seeking aesthetic procedures, it is still a very small number who are also addressing all the other issues that pertain to why their skin is aging, or their appearance is changing.

How exactly do you utilize peptides?

Dr. Yurth: When dealing with aging, one of the keys is to replace what we’re losing. As I age, my hormones diminish. At a relatively young age, both men and women start to lose testosterone, estrogen, and progesterone. Restoring those levels is paramount. You need to get them back to youthful levels even before you start considering peptides for longevity. Peptides will do very little if you do not have adequate basic hormone levels.

For patients with appropriate hormone levels, the first concept to understand is that body makes endogenous peptides. Think about peptides as small chains of amino acids. One peptide everyone knows is insulin; when you eat glucose, your body makes insulin. The body produces hundreds of other peptides like that for various functions. For instance, the gut makes a peptide called BPC (body protective compound) 157 in response to tissue that needs repair. If I have an injury, if my skin is getting laxer, or if I undergo a laser procedure, BPC is produced in higher concentrations to help fight and recover from that injury. I cannot make as much BPC as I age, but I can take it exogenously, utilizing an external source that is identical to the peptide that my body makes. You can use that for repair purposes after procedures, or even preventatively on occasion, to keep the body in a more reparative mode.

There are also thymic peptides. When we are babies, our thymus gland is huge; if you take an X-ray of a baby’s chest, this giant gland sitting in their chest looks like a mass. As we hit puberty, it starts to shrink. By the time we are older, it is a small, fatty nub. It is no longer doing its job of making thymic peptides, which help support our immune system and, by extension, our skin integrity. With a diminished immune system, the skin is prone to more rashes. It will react more to irritants. A patient might get psoriasis because their thymus gland is not producing the necessary tools to train the immune system. However, we can give back things like thymosin alpha 1—which is actually a drug in other countries, called Zadaxin. It is basically an identical peptide to what my body makes, and it will support my immune system and help me to heal. Additionally, because so much of aging involves the decline of our immune system—that’s why we die of viruses, cancers, etc—we can prevent a lot of that by taking thymosin alpha 1 periodically. I would suggest dosing approximately four times per year and definitely using it after an aesthetic procedure such as a facelift.

The other peptide that the thymus gland makes is thymosin beta 4, which improves fibroid collagen. It is coming in as a repair part. Think about what the body is trying to do when there is an injury, or think of all aging as somewhat of a long-term injury. We have thymosin alpha 1 coming in to support the immune system and thymosin beta 4 coming in to help restore collagen, fibrin activation, and growth factors. So, those two peptides, along with BPC, can be used to restore youthful levels in the body, just like the youthful levels of hormones, so the body can heal, recover, and age the way it did at a younger age.

We also can do a lot with topical peptides, which is kind of amazing. We have seen this start to penetrate the skincare industry. GHK-Cu, for example, is a peptide that changes more than 500 genes in the body in a positive way. It can be taken systemically, but it also can be used topically on your skin or to grow hair. It is endogenously made by our bodies, but we can give it exogenously to get more of it. We can mix GHK-Cu with other peptides like bufazel or argireline, which have a neurotoxin-like effect. You can utilize those topically in between procedures to help maintain skin integrity. GHK-Cu is such a powerful, powerful peptide in the aesthetic field, but we also use it a lot for recovery from injuries—the same kinds of things we think about with aging.

If you think about it, when we’re at our best—let’s say 18 years old—we heal well and recover well. All our hormones are at their best. If we put those all back to where they were—and if we start doing that in our 30s or 40s instead of in our 60s—can we actually prevent a lot of these age-related conditions that are occurring, including some of those aesthetic changes, such as the saggy skin, the loss of muscle, the increase in fat mass that all occur with aging?

The last peptide that we lose when we are aging is insulin-like growth factor (IGF). IGF is most known because of growth hormone. You hear about celebrities using growth hormone and how important it is for sleep, skin repair, muscle building, and more. When we are young, we have high levels of growth hormone; as we age, growth hormone diminishes and we lose fat volume under our skin, but we gain it viscerally. We also lose muscle mass because of that drop in growth hormone. To compensate, you can use growth hormone itself or you can use growth hormone secretagogues, which are little peptides that tell the liver to produce IGF. It has a similar effect to growth hormone except much more physiologic; you don’t get as many side effects.

So, we can take all these hormones and peptides. Let’s say a patient comes in for their first neurotoxin treatment at the age of 30. What if somebody at that point started preaching what could be done preventatively from a longevity perspective so that we don’t see all these age-related effects, instead of playing catch up when people are 50 and 60? What if we actually started people utilizing some of these tools at a younger age? Could we prevent a lot of these age-related effects? That is why I would really like to see these two fields a little bit more cohesive. It doesn’t mean that every aesthetic provider needs to learn all of this. It’s a lot to learn. However, they could have a referral pattern whereby they are sending patients to a clinician who is optimizing the inside while they are doing all this great work on the outside.

You have a background as an orthopedic surgeon. Can clinicians in fields like that promote the potential aesthetic benefits of longevity therapies, and conversely, do you prefer that patients at aesthetic clinics potentially undergo treatments that are better for their wellness overall?

Dr. Yurth: I got into this field because it was the last thing we were thinking about as orthopedists. We would stick steroids in a joint repeatedly until replacing the joint. Approximately 20 years ago, I became very disillusioned with the fact that I didn’t really seem to ever make anybody better, so I decided to learn how to help people to heal better. I learned about hormones, nutrients, and peptides that we can utilize to heal people. Still, in a 15-minute appointment, you don’t really have the opportunity to teach people this, which is why I opened Boulder Longevity Institute 18 years ago to bridge that gap. If somebody comes in with an orthopedic injury, even in their 20s, and I can teach them how to avoid it developing into arthritis, it will help them in every aspect of their life.

My primary goal is to get people to understand that we really have to work on aesthetics with everything. We need to be working on our immune system. We need to be working on restoring all those elements that support our collagen production, our muscle production, our muscle mass, our healthy fat mass, and our brown fat mass. And there is no way to do that, honestly, without these tools. You just succumb to aging. And you can keep doing face lifts and procedures like that, but it’s not addressing the root cause of the issues.

SAFE, EFFECTIVE USE OF STEM CELLS

How much does longevity in the sense of health overlap with aesthetics in the sense of looks?

Dr. Judd: If you are not healthy inside, you will not look great no matter what you try to do on the outside. So you can see inflammation in somebody’s face. You can see fluid retention. You can see that they are not clearing toxins because they look congested. You can see swelling. Aesthetic treatment alone will not shine through. You will not achieve the same effects.

What is the healthiest way to look younger?

Dr. Judd: The healthiest way to look younger is to make sure that, at a cellular level, you are healthy—ensure that your cells are getting the nutrients they need and your body is able to perform its functions. The body itself is so much more complicated than we can understand, and it will always do a better job than we can on this whack-a-mole, downstream approach. It comes down to the cell itself.

What do stem cell injections accomplish in that vein?

Dr. Judd: When parts of the body have been deteriorating for a long time, it can be really difficult to fix. Just giving the body nutrients, exercise, and sleep from that point on will not reverse the effects of previous damage.

With stem cells, we can go back in time and reverse things—when we use them appropriately. Stem cells are still controversial and some aspects still need to be sorted out; currently, there are US Food and Drug Administration (FDA) approved ways to receive stem cells in the US. The FDA has approved the use of autologous stem cells that are harvested and grown at an approved laboratory. Those can then be used intravenously through the whole body or in a specific area such as a joint, the face, the hair, etc.

Why else are autologous stem cells preferred?

Dr. Judd: Stem cells are expensive. To really reverse aging in the body, you need a lot of them; I have patients who do 100 million of their own stem cells every quarter. The cost of purchasing 100 million umbilical or allogenic stem cells can be exorbitant; companies often charge $3,000 to $5,000 per 10 million cells. Using your own cells, however, you can have 100 million for a fraction of the cost, and they are your own, so you don’t have any risk of rejection or bringing new genetic information into the body. It is important to be aware of the different types of stem cells and risks associated. A lot of companies are running to that market because the demand exists. Patients need to be careful about knowing what they’re getting.

We need to be careful with toxicity because our bodies are already on high alert right now. We are seeing the effects of COVID-19, even in the cosmetic world. Our bodies seem to be more prone right now to reacting to something that’s not theirs. Breast implant illness is another example. Because of the toxicity in the environment, the stress we are under, and deficiencies in nutritional density in food today, our bodies were already vulnerable, and COVID-19 made it worse. Think of it as a business: Your body is asking, “What do you want me to do today? And what are you giving me to do those jobs?” We are up against challenging odds, even when we are doing everything perfectly—getting sleep, managing stress, drinking enough water, and exercising. I am always thinking about how we can do things better. Even functional medicine relies too heavily on supplements, but those, too, can be taxing on the body.

What is the best way to utilize stem cells?

Dr. Judd: I have patients who come in for stem cell treatments every quarter, and we often pair it with intravenous ozone, which pulls toxins out of the body. That combination of restoring while also removing toxins has been very effective for longevity.

What next steps would you like to see in terms of research and development, validations, approvals, awareness, etc?

Dr. Judd: On a policy level, I would like to see the government taking steps aimed at safety and not standing in the way of something that can really improve the health of people because it may impact other areas of medicine from which they benefit. Beyond that, if somebody is healthy, we are just trying to get them as early as possible. Get them banked. Banking your cells can be done at a minimal cost per year, and there is no downside to it. You can just get them when you need them, and that’s a really good thing for the future. We don’t know where we’re headed.

Aesthetics should be more than just coming in for procedures. There should be talk about what is coming through the skin and why. Just a little bit of an education would be really important and contribute to better outcomes.

APPROPRIATE PROTOCOLS

In what ways are longevity and overall wellness related, or should they be related?

Dr. Kaufmann: They are absolutely related. Longevity is an extension of wellness. If you are not well, you will not live long. First, you need to take care of standard health and wellness. Beyond that are prophylactic measures such as getting tested early, seeing a physician regularly, etc. Longevity is that next step. It is doing things with the knowledge that illness is coming. It is not just diet and exercise but, for example, lowering risks of certain disease. It’s free radical scavenging. It’s increasing DNA repair rates. It’s, basically, trying to avoid morbidity and mortality, a step beyond general wellness.

In the context of aesthetics, how important is wellness to your looks?

Dr. Kaufmann: It is extremely important, and it goes both ways. If you are not well on the inside, I don’t care what you do to your outside; you will not look well. It is the canary in the coal mine, at least in terms of medical practicality: If your skin is a little discolored or if you have glips, globs, scars, or patches, it just represents pathology that is coming from within. It is, in fact, a reflection of how well you are. Conversely, if you take care of your outside, you are more likely to be taking care of your inside. We kid around about what we do on the outside, and I call a lot of it spackle. You can inject neurotoxin and you can fill, and you can make your exterior look as beautiful as you want, but much like spackle on a wall, filling in the holes doesn’t mean the wall is solid. It may make you feel better, but it’s not really doing anything. On the other hand, there are some things that you really can put on your skin that make you significantly better. So, it goes both ways. The inner reflects the outer and the outer can help the inner.

Why is developing detailed protocols important in the pursuit of being well on both the inside and outside?

Dr. Kaufmann: We do personalize our treatments. No two people are identical, for the most part. Where they live, what they eat, how they exercise, what their genetics are, and so many other factors must be considered. However, there are some baseline protocols that I designed that can be customized for each patient. People like the idea of knowing what they are going to do. I like to call it a protocol because it gives people the scientific idea that they are doing something more than just popping a few random vitamins.

How much work went into designing these baseline protocols?

Dr. Kaufmann: Many years. The protocol started with the idea of, “Why do you age in the first place?” I went down this road a decade ago, when there were no widely acknowledged hallmarks of aging. It had been described in a paper, but few people had really paid attention. I was a cell biologist before I went to medical school. Starting from the absolute basics, I decided that you age because your cells age, and I organized cellular aging in seven subcategories. Within those categories, there is further and further breakdown. It is about accepting simple concepts such as DNA, mitochondrial issues, pathways, etc. Next, I tried to evaluate all of the things that people were starting to take for longevity. There weren’t that many at the time, but I really wanted to know, why would someone take Agent X? I read every paper I could get my hands on. For example, veratrole and astaxanthin: What did they do for your DNA and how do we know that? What did they do for your mitochondria, etc? I developed a rating system to compare efficacy of evidence. Every agent could now be assigned a seven-digit code that tells what we know about it. How strong is the evidence, and what does it do in each category? Some agents do some things in every category, while some are just specialists—they are exceptionally good in waste management or DNA repair, for example. So, the rating system gives you an indication of where to start choosing from the various options. Once you see why you are aging and what your choices are, you can put together this algorithm to determine what is right for you. It is a very complex etiology. The first number is DNA—alterations in that category. We’re looking at epigenetic modification, we’re looking at telomeres, and we’re looking at heterochromatin distribution within the nucleus. If there is no evidence in any paper anywhere that it does absolutely anything, it gets a 0. If there is good evidence in test tubes or cultures, or it’s just a brilliant idea, it would get a 1. If there is evidence in non-human mammal models that is significant, it gets a 2. If there is good human evidence, it would get a 3. The numbers are very conservative. If there is no human study, it does not get a human rating. If you look at the numbers, you will see a huge distribution. There are a lot of zeros and a lot of twos. Agents that are very popular tend to have more threes because someone has actually spent the money on research to answer the questions.

Whether it’s your specific protocols or just the overall concept, how much has this permeated the field?

Dr. Kaufmann: That’s a really good question. It is so hard to gauge. I do not have a huge facility. I have a consulting service through which I see some patients privately, and I have an online telemedicine practice, but I don’t have hundreds and hundreds of people coming. I will tell you, without any advertising whatsoever, I have sold a lot of books. People are so interested, so I have probably contributed to hundreds of thousands of protocols through my first two books, and I am currently working on two more.

How closely do you monitor everything to ensure that your protocols are updated when, for instance, something needs to be upgraded from a two to a three for the fourth tenet?

Dr. Kaufmann: It is a full-time job, which is ironic. It’s not my full-time job, but it should be, honestly. I am a clinical anesthesiologist. This is just a ridiculously ornate hobby that has grown out of proportion. Every day I am finding new agents. Many of them are over-the-counter options. I use 13 pharmaceuticals now for myself and for my private patients.

You also have club exosome. What can you tell us about that?

Dr. Kaufmann: I inject exosomes into my face and my skin all the time, as well as intravenously. I started doing exosomes treatments for a few of my friends, and they loved it so much that they started referring more people. It turned into a club that we run out of Las Vegas, quarterly, because people just cannot seem to get quality exosomes or find physicians who know how to use them appropriately. Obviously, they are not regulated. In terms of a line between aesthetics and health, however, I truly believe in exosomes bringing those two concepts together. The skin is just an organ; it is the organ that we see, but it’s just like everything else. You need to keep it healthy and keep it on a longevity protocol.

Are you concerned about the regulatory aspect?

Dr. Kaufmann: We have a good system. My partner vets every patient first. I also have a 5-page consent form that was written by an international attorney. We make it clear that this is not FDA-approved, what the risks and benefits are, etc. With that being said, by the time someone decides that they want exosomes, they usually understand that there are drawbacks, limitations, and legal issues. It has become so popular, though. We have had to just cut people off on some days.